Causes and incidence Clinical features Diagnostic measures
Aortic insuffi ciency
● Results from rheumatic fever, syphilis, hypertension, or endo- carditis, or may be idiopathic
● Associated with Marfan syn- drome
● Most common in males
● Associated with ventricular septal defect, even after surgi- cal closure
● Dyspnea, cough, fatigue, palpitations, angina, syncope
● Pulmonary vein congestion, heart failure, pulmonary edema (left-sided heart failure),
“pulsating” nail beds (Quincke’s sign)
● Rapidly rising and collapsing pulses (pulsus biferiens), cardiac arrhythmias, wide pulse pressure in severe insuffi ciency
● Auscultation reveals a third heart sound (S3) and a diastolic blowing mur- mur at left sternal border
● Palpation and visualization of apical impulse in chronic disease
● Cardiac catheterization: reduction in arterial diastolic pressures, aortic insuffi ciency, other val- vular abnormalities, and increased left ventricular end-diastolic pressure
● X-ray: left ventricular enlargement, pulmonary vein congestion
● Echocardiography: left ventricular enlarge- ment, alterations in mitral valve movement (indi- rect indication of aortic valve disease), and mitral thickening
● Electrocardiography (ECG): sinus tachycardia, left ventricular hypertrophy, and left atrial hyper- trophy in severe disease
Aortic stenosis
● Results from congenital aor- tic bicuspid valve (associated with coarctation of the aorta), congenital stenosis of valve cusps, degenerative calcifi ca- tions caused by mechanical stress, diabetes mellitus, hypercholesterolemia, or hypertension
● Most common in males
● Exertional dyspnea, paroxysmal noc- turnal dyspnea, fatigue, syncope, angina, palpitations
● Pulmonary vein congestion, heart fail- ure, pulmonary edema
● Diminished carotid pulses, decreased car- diac output, cardiac arrhythmias; may have pulsus alternans
● Auscultation reveals systolic murmur at base or in carotids and, possibly, a fourth heart sound (S4)
● Cardiac catheterization: pressure gradient across valve (indicating obstruction), increased left ventricular end-diastolic pressures
● X-ray: valvular calcifi cation, left ventricular enlargement, and pulmonary venous congestion
● Echocardiography: thickened aortic valve and left ventricular wall
● ECG: left ventricular hypertrophy
Mitral insuffi ciency
● Results from rheumatic fever, hypertrophic cardiomyopathy, mitral valve prolapse, myocar- dial infarction, severe left-sided heart failure, or ruptured chor- dae tendineae
● Associated with other con- genital anomalies such as trans- position of the great arteries
● Rare in children without other congenital anomalies
● Orthopnea, dyspnea, fatigue, angina, palpitations
● Peripheral edema, jugular vein disten- tion, hepatomegaly (right-sided heart failure)
● Tachycardia, crackles, pulmonary edema
● Auscultation reveals a holosystolic murmur at apex, possible split second heart sound (S2), and an S3
● Cardiac catheterization: mitral insuffi ciency with increased left ventricular end-diastolic vol- ume and pressure, increased atrial pressure and pulmonary artery wedge pressure (PAWP), and decreased cardiac output
● X-ray: left atrial and ventricular enlargement, pulmonary venous congestion
● Echocardiography: abnormal valve leafl et motion, left atrial enlargement
● ECG: may show left atrial and ventricular hyper- trophy, sinus tachycardia, and atrial fi brillation Mitral stenosis
● Results from rheumatic fever (most common cause), atrial myxoma, or endocarditis
● Most common in females
● May be associated with other congenital anomalies
● Exertional dyspnea, paroxysmal noc- turnal dyspnea, orthopnea, weakness, fatigue, palpitations
● Peripheral edema, jugular vein disten- tion, ascites, hepatomegaly (right-sided heart failure in severe pulmonary hyper- tension)
● Crackles, cardiac arrhythmias (atrial fi brillation), signs of systemic emboli
● Auscultation reveals a loud fi rst heart sound (S1) or opening snap and a dia- stolic murmur at the apex
● Cardiac catheterization: diastolic pressure gradi- ent across valve; elevated left atrial pressure and PAWP with severe pulmonary hypertension and pulmonary artery pressures; elevated right-sided heart pressure; decreased cardiac output; and abnormal contraction of the left ventricle
● X-ray: left atrial and ventricular enlargement, enlarged pulmonary arteries, and mitral valve calcifi cation
● Echocardiography: thickened mitral valve leaf- lets, left atrial enlargement
● ECG: left atrial hypertrophy, atrial fi brillation, right ventricular hypertrophy, and right axis deviation
Valvular heart disease ❍ 121
Causes and incidence Clinical features Diagnostic measures
Mitral valve prolapse syndrome
● Cause unknown; researchers speculate that metabolic or neuroendocrine factors cause constellation of signs and symptoms
● Most commonly affects young women but may occur in both sexes and in all age-groups
● May produce no signs or may produce signs and symptoms of mitral insuffi ciency
● Chest pain, palpitations, headache, fatigue, exercise intolerance, dyspnea, syncope, light-headedness, mood swings, anxiety, panic attacks
● Auscultation typically reveals a mobile, midsystolic click, with or without a mid-to-late systolic murmur
● Two-dimensional echocardiography: prolapse of mitral valve leafl ets into left atrium
● Color-fl ow Doppler studies: mitral insuffi ciency
● Resting ECG: ST-segment changes, biphasic or inverted T waves in leads II, III, or AV
● Exercise ECG: evaluates chest pain and arrhythmias
Pulmonic insuffi ciency
● May be congenital or may result from pulmonary hypertension
● May rarely result from prolonged use of pressure monitoring catheter in the pulmonary artery
● Dyspnea, weakness, fatigue, chest pain
● Peripheral edema, jugular vein distention, hepatomegaly (right- sided heart failure)
● Auscultation reveals diastolic murmur in pulmonic area
● Cardiac catheterization: pulmonic insuffi ciency, increased right ventricular pressure, and associated cardiac defects
● X-ray: right ventricular and pulmonary arterial enlargement
● ECG: right ventricular or right atrial enlargement
Pulmonic stenosis
● Results from congenital stenosis of valve cusp or rheumatic heart disease (infrequent)
● Associated with other congenital heart defects such as tetralogy of Fallot
● Asymptomatic or symptomatic with exertional dyspnea, fatigue, chest pain, syncope
● May lead to peripheral edema, jugular vein distention, hepatomegaly (right-sided heart failure)
● Auscultation reveals a systolic murmur at the left sternal border, a split S2 with a delayed or absent pulmonic component
● Cardiac catheterization: increased right ventricular pressure, decreased pulmonary artery pressure, and abnormal valve orifi ce
● ECG: may show right ventricular hypertrophy, right axis deviation, right atrial hypertrophy, and atrial fi brillation
Tricuspid insuffi ciency
● Results from right-sided heart failure, rheumatic fever and, rarely, trauma and endocarditis
● Associated with congenital disorders
● Dyspnea and fatigue
● May lead to peripheral edema, jugular vein distention, hepatomegaly, ascites (right-sided heart failure)
● Auscultation reveals possible S3 and systolic murmur at lower left sternal border that increases with inspiration
● Right-sided heart catheterization: high atrial pressure, tricuspid insuffi ciency, and decreased or normal cardiac output
● X-ray: right atrial dilation, right ventricular enlargement
● Echocardiography: shows systolic prolapse of tricuspid valve, right atrial enlargement
● ECG: right atrial or right ventricular hypertrophy, atrial fi brillation Tricuspid stenosis
● Results from rheumatic fever
● May be congenital
● Associated with mitral or aortic valve disease
● Most common in females
● May be symptomatic with dyspnea, fatigue, syncope
● Possibly peripheral edema, jugular vein distention, hepatomegaly, ascites (right-sided heart failure)
● Auscultation reveals diastolic murmur at lower left sternal border that increases with inspiration
● Cardiac catheterization: increased pressure gradient across valve, increased right atrial pressure, and decreased cardiac output
● X-ray: right atrial enlargement
● Echocardiography: leafl et abnormality, right atrial enlargement
● ECG: right atrial hypertrophy, right or left ventricular hypertrophy, and atrial fi brillation
Types of valvular heart disease (continued)
Review questions
1. While auscultating the heart sounds of a patient with mitral insuffi ciency, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this extra heart sound as:
A. a fi rst heart sound (S1).
B. a third heart sound (S3).
C. a fourth heart sound (S4).
D. a mitral murmur.
Correct answer: B An S3 is heard following an S2, indicating that the patient is experiencing heart failure and results from increased fi lling pressures. Option A (S1) is a normal heart sound made by the closing of the mitral and tricuspid valves. Option C (S4) is heard before S1 and is caused by resistance to ventricular fi lling. Option D (murmur of mitral insuffi ciency) occurs during systole and is heard when there’s turbu- lent blood fl ow across the valve.
2. A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do?
A. Consider this to be a normal fi nding for his age and race.
B. Recommend he have his blood pressure rechecked in 1 year.
C. Recommend he have his blood pressure rechecked within 2 weeks.
D. Recommend he go to the emergency department for further evaluation.
Correct answer: C A blood pressure of 150/90 mm Hg should be rechecked within 2 weeks according to current recommendations. If confi rmed, assessment and treatment should be initiated by the practitioner.
Option A is incorrect because although hypertension is more prevalent among blacks, a blood pressure of 150/90 mm Hg isn’t considered normal. Option B is incorrect because a person with a blood pressure of 150/90 mm Hg shouldn’t wait as long as 1 year to have it rechecked. Option D is incorrect because he doesn’t need to be treated on an emergency basis, but he should have his blood pressure monitored.
3. The nurse is administering warfarin (Coumadin) to a patient with deep vein thrombophlebitis. Which labo- ratory value indicates warfarin is at therapeutic levels?
A. PTT 1½ to 2 times the control B. PT 1½ to 2 times the control C. INR of 3 to 4
D. Hematocrit of 32%
Correct answer: B Warfarin is at therapeutic levels when the patient’s PT is 1½ to 2 times the control.
Higher values indicate increased risk of bleeding and hemorrhage, and lower values indicate increased risk of blood clot formation. Option A is incorrect because heparin, not warfarin, prolongs PTT. Option C is incorrect because although the INR may also be used to determine if warfarin is at a therapeutic level, an INR of 2 to 3 is considered therapeutic. Option D is incorrect because hematocrit doesn’t provide information on the effectiveness of warfarin; however, a falling hematocrit in a patient taking warfarin may be a sign of hemorrhage.
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Review questions ❍ 123
4. A patient is receiving captopril for heart failure. The nurse should notify the practitioner that the medication therapy is ineffective if an assessment reveals:
A. a skin rash.
B. peripheral edema.
C. a dry cough.
D. postural hypotension.
Correct answer: B Peripheral edema is a sign of fl uid volume overload and worsening heart failure. The other options (a skin rash, dry cough, and postural hypotension) are adverse reactions to captopril, but they don’t indicate that therapy isn’t effective.
5. A 60-year-old male patient is suspected of having coronary artery disease. Which noninvasive diagnostic method would the nurse expect to be ordered to evaluate cardiac changes?
A. Cardiac biopsy
B. Cardiac catheterization C. MRI
D. Pericardiocentesis
Correct answer: C MRI is a noninvasive procedure that aids in the diagnosis and detection of thoracic aortic aneurysm and evaluation of coronary artery disease, pericardial disease, and cardiac masses. Car- diac biopsy (Option A), cardiac catheterization (Option B), and pericardiocentesis (Option D) are invasive techniques used to evaluate cardiac changes.
6. When evaluating an ECG strip of a patient on a telemetry unit, the nurse notices the patient is having pre- mature ventricular contractions (PVCs). What criterion on the ECG strip does the nurse use to evaluate the pres- ence of PVCs?
A. An indiscernible PR interval B. P waves that appear erratic
C. P waves that have a sawtooth confi guration D. A QRS complex followed by a compensatory pause
Correct answer: D In PVCs, the ECG shows a QRS complex followed by a compensatory pause that ends when the underlying rhythm resumes. Options A and B are ECG criteria used to evaluate atrial fi brillation. Option C is used to describe criteria for atrial fl utter.
7. When locating Erb’s point to hear aortic and pulmonic sounds, the nurse should place the stethoscope at the:
A. fi fth intercostal space near the midclavicular line.
B. fi fth intercostal space along the left sternal border.
C. second intercostal space at the left sternal border.
D. third intercostal space at the left sternal border.
Correct answer: D Erb’s point is located at the third intercostal space at the left sternal border. The fi fth intercostal space near the midclavicular line (Option A) is used to listen to the mitral area. The fi fth intercostal space along the left sternal border (Option B) is the location for the tricuspid area. The second intercostal space at the left sternal border (Option C) is the location for the pulmonic area.
8. When caring for a patient with arterial occlusive disease, which of the following home health care instructions is most appropriate for the nurse to give to the patient?
A. “You should massage your legs to relieve pain.”
B. “It’s best to sit and rest for several hours a day.”
C. “Make sure the head of your bed is slightly elevated when sleeping.”
D. “It’s best to wear tight socks instead of no socks.”
Correct answer: C The patient should make sure the head of the bed is slightly elevated to aid perfu- sion to the lower extremities. The patient shouldn’t massage his legs (Option A) because doing so could further damage tissue. Sitting for several hours a day (Option B) isn’t recommended. The patient should wear loose clothing, not constrictive clothing such as socks with tight elastic (Option D), to avoid com- pressing the vessels in the legs.
9. The nurse prepares to administer an ACE inhibitor to a patient with an acute MI for which reason?
A. To minimize platelet aggregation B. To reduce preload and afterload
C. To reduce myocardial oxygen consumption D. To decrease myocardial oxygen demand
Correct answer: B ACE inhibitors reduce preload and afterload. Antiplatelet drugs minimize platelet aggregation (Option A). Nitrates reduce myocardial oxygen consumption (Option C). Beta-adrenergic blockers reduce the workload of the heart and myocardial oxygen demand (Option D).
10. Which of the following conditions can cause right-sided heart failure?
A. A ventricular septal defect B. An anterior MI
C. An atrial septal defect D. Constrictive pericarditis
Correct answer: C An atrial septal defect can lead to right-sided heart failure. Left-sided heart failure can result from a ventricular septal defect (Option A), an anterior MI (Option B), or constrictive pericardi- tis (Option D).
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❖ Introduction
Blood circulates in the cardiovascular system, carrying oxygen to the cells and removing wastes from them The continuous movement of blood also provides a defense against infection and injury, which are more likely to occur with stasis
The cellular components of red blood cells (RBCs), white blood cells (WBCs), and platelets are subject to pathologic alterations that can cause severe disruptions in homeostasis
Nursing history
◆The nurse asks the patient about his chief complaint
◆A patient with a hematologic disorder may report any of the following signs or symptoms: aching bones, anorexia, bleeding gums, bruising, dyspnea, fatigue, infection, lethargy, malaise, nausea, nosebleeds, numbness, paresthesia, swollen and tender lymph nodes, tarry stools, tingling, vomiting, and, in women, heavy menses
◆The nurse then questions the patient about his present illness
◗ Ask the patient about his symptoms, including when they started, associated symptoms, location, radiation, intensity, duration, and frequency
◗ Question the patient about what factors make the symptoms feel better or worse
◆The nurse asks about medical history
◗ Ask about the present and past use of prescription and over-the-counter drugs, herbal remedies, and vitamin and nutritional supplements because many of these products can interfere with hemato- logic function
◗ Ask the patient about previous problems, such as anemia, leukemia, enlarged lymph nodes, malabsorption, and spleen or liver disorders
◗ Ask about previous treatments, such as blood transfusions and radiation treatments
◗ Question him about his diet, and look for defi ciencies—for example, in folic acid, iron, or vitamin B12
◆The nurse then assesses the family history
◗ Ask about a family history of blood and lymph disorders, acquired and genetic
◗ Ask about a family history of cancers involving the blood or lymph systems
◆The nurse obtains a social history
◗ Ask about ethnic background and race
◗ Question the patient about use of cigarettes, alcohol, and recreational drugs
◗ Ask him about occupational or household exposure to radiation or chemicals Physical assessment
◆The nurse begins with inspection
◗ Observe the patient’s general appearance; does he appear alert, confused, tired, or irritable?
◗ Note the patient’s skin color; look for bruising, diaphoresis, dyspnea, lesions, petechiae, and swelling of the lymph nodes
◗ Note the size and color of his tongue
◗ Ask the patient whether his abdominal girth is enlarged
◆The nurse uses auscultation
◗ Listen to heart sounds, noting abnormal sounds, rhythms, or tachycardia
◗ Auscultate the abdomen, noting bowel sounds, bruits, friction rubs, or venous hums
8 Hematologic disorders Hematologic disorders
◆Next, the nurse uses palpation
◗ Palpate the lymph nodes, noting consistency, mobility, shape, size, and tenderness; compare nodes on one side of the body with those on the other side
◗ Palpate the abdomen, noting ascites, enlarged organs, or tenderness
◆The nurse then uses percussion
◗ Percuss the liver and spleen to estimate size
◗ Note the size and location of other abdominal organs
❖ Anemias
Anemia exists when the number of RBCs in a designated volume of blood is less than normal Anemias include those from blood loss or hemolysis and aplastic, iron defi ciency, and megaloblastic anemias (see Types of anemia, pages 127 to 128)
❖ Disseminated intravascular coagulation
Description◆Disseminated intravascular coagulation (DIC) is a serious blood coagulation disorder that occurs as a complication of conditions that accelerate blood clotting.
◆It’s characterized by suppression of the fi brinolytic system and the development of small clots in the microcirculation, which consumes clotting factors, resulting in excessive bleeding
◆The disorder can result from septicemia; obstetric complications, such as abruptio placentae and amniotic fl uid embolism; cancer; blood transfusion reactions; and cirrhosis
◆Tissue hypoxia and multiple organ failure can occur; the mortality rate can exceed 80%
Signs and symptoms
◆The main sign is abnormal bleeding, evidenced by cutaneous oozing, petechiae, ecchymoses, hematomas, GI bleeding, and bleeding from wounds and I.V. sites
◆Signs of organ compromise include dyspnea, oliguria, and muscle or abdominal pain; shock can also occur
Diagnosis and treatment
◆Laboratory tests show a steadily decreasing platelet count, elevated prothrombin time (PT) and partial thromboplastin time (PTT), elevated fi brin degradation products, and decreased hemoglobin and hematocrit
◆Medical management aims to identify and treat the underlying disorder, promote oxygenation, replace fl uids and electrolytes, and provide hemodynamic support
◆Treatments include clotting factor and blood replacement and I.V. heparin Nursing interventions
◆Early recognition of the onset of DIC improves patient outcomes, so closely monitor patients at risk, watching for signs and symptoms
◆For a patient with DIC, avoid trauma to skin or wounds to minimize bleeding, protect the patient from injury, and avoid dislodging clots
◆Apply pressure to puncture sites until bleeding stops
◆Monitor the patient’s vital signs, and administer I.V. fl uids and blood products as ordered
◆Monitor the patient’s intake and output carefully and record blood loss
◆Watch for signs of tissue ischemia and failure
◆Provide emotional support to the patient and family
❖ Hemophilia
Description
◆Hemophilia is a hereditary bleeding disorder that results from the lack of specifi c clotting factors
◆Two main forms exist: Hemophilia A, called “classic hemophilia,” results from defi ciency of factor VIII and is seen in 80% of cases, and hemophilia B, called “Christmas disease,” results from defi ciency of factor IX and is seen in 15% of cases; the two types are clinically indistinguishable
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Hemophilia ❍ 127